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Efficacy and Safety of Tacrolimus Versus Cyclosporine in Children WithSteroid-Resistant Nephrotic Syndrome: A Randomized Controlled Trial

Swati Choudhry, MD,1 Arvind Bagga, MD,1 Pankaj Hari, MD,1 Sonika Sharma, MSc,2

Mani Kalaivani, MSc,3 and Amit Dinda, PhD4

Background: To examine whether tacrolimus is more effective and safe than cyclosporine (CsA) ininducing remission in patients with steroid-resistant nephrotic syndrome (SRNS).

Study Design: Randomized controlled trial, nonblind, parallel group.Settings & Participants: Tertiary-care hospital; 41 consecutive patients with idiopathic SRNS,

estimated glomerular filtration rate greater than 60 mL/min/1.73 m2, and histological characteristicsshowing minimal change disease, focal segmental glomerulosclerosis, or mesangioproliferative glomer-ulonephritis were randomly assigned to treatment with tacrolimus (n � 21) or CsA (n � 20).

Intervention: Tacrolimus (0.1 to 0.2 mg/kg/d) or CsA (5 to 6 mg/kg/d) for 1 year; cotreatment withalternate-day prednisolone and enalapril.

Outcomes: Patients achieving complete remission (urinary protein-creatinine ratio � 0.2 g/g andserum albumin � 2.5 g/dL) or partial remission (urinary protein-creatinine ratio, 0.2 to 2 g/g, and serumalbumin �2.5 g/dL) at 6 and 12 months; time to remission; proportion with relapses; side effects.

Results: No patient was lost to follow-up. After 6 months of therapy, remission occurred in 18 (85.7%)and 16 patients (80%) treated with tacrolimus and CsA, respectively (relative risk [RR], 1.07; 95%confidence interval [CI], 0.81 to 1.41). Rates of remission at 12 months were also similar (RR, 1.14; 95%CI, 0.84 to 1.55). The proportion of patients who experienced relapse was significantly greater in thosereceiving CsA compared with tacrolimus (RR, 4.5; 95% CI, 1.1 to 18.2; P � 0.01). The decrease in bloodcholesterol levels was greater with tacrolimus compared with CsA (difference in mean values, 45.1mg/dL; 95% CI, 19.1 to 71.2). Persistent nephrotoxicity necessitating stoppage of medicine was seen in4.7% and 10% patients, respectively. Cosmetic side effects (hypertrichosis and gum hypertrophy) weresignificantly more frequent in CsA-treated patients (P � 0.001).

Limitations: Single-center study, small sample size, and short duration of follow-up.Conclusions: Tacrolimus or CsA in combination with low-dose steroids show similar efficacy in

inducing remission in patients with SRNS. Therapy with tacrolimus is a promising alternative to CsA inview of the lower risk of relapses and lack of cosmetic side effects.Am J Kidney Dis 53:760-769. © 2009 by the National Kidney Foundation, Inc.

INDEX WORDS: Focal segmental glomerulosclerosis; minimal change disease; tacrolimus; cyclospor-ine; steroid-resistant nephrotic syndrome.

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anagement of idiopathic steroid-resistantnephrotic syndrome (SRNS) in children

s challenging. Patients are at risk of complica-ions of nephrotic syndrome, side effects of im-unosuppressive agents, and progressive kidney

From the Divisions of 1Nephrology and 2Genetics, Depart-ent of Pediatrics; and Departments of 3Biostatistics and

Pathology, All India Institute of Medical Sciences, Ansariagar, New Delhi, India.Received June 20, 2008. Accepted in revised form Novem-

er 13, 2008. Originally published online as doi:0.1053/j.ajkd.2008.11.033 on March 6, 2009.

Trial Registration: www.cochrane-renal.org; study num-er: CRG030600042.Address correspondence to Arvind Bagga, MD, Department

f Pediatrics, All India Institute of Medical Sciences, Ansariagar, New Delhi 110029, India. E-mail: arvindbagga@otmail.com© 2009 by the National Kidney Foundation, Inc.0272-6386/09/5305-0008$36.00/0

tdoi:10.1053/j.ajkd.2008.11.033

American Journal60

isease.1 The aim of therapy therefore is induc-ion of remission while avoiding medication-ssociated toxicity. Although multiple agents haveeen used in patients with SRNS, the optimalreatment regimen is not defined. A lack of pro-pective trials comparing the efficacy of immuno-uppressive medications has resulted in the ab-ence of treatment guidelines. Results fromrospective studies, including randomized trials,uggest that treatment with oral cyclophospha-ide is not effective in patients with SRNS.2,3,4

indings from observational studies comprisingntravenous (IV) corticosteroids or IV cyclophos-hamide showed efficacy rates ranging from5% to 60%.5,6 Treatment with these agents wasssociated with significant side effects. Duringhe last 2 decades, cyclosporine (CsA) has beensed in patients with SRNS with efficacy ratesanging between 30% and 70%.7-9 However,

reatment with CsA is associated with nephrotox-

of Kidney Diseases, Vol 53, No 5 (May), 2009: pp 760-769

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Tacrolimus Versus CsA in Nephrotic Syndrome 761

city and cosmetic side effects.10,11 Data fromransplant recipients suggest that tacrolimus is aore potent immunosuppressive agent than CsA

nd is associated with minimal cosmetic sideffects and lower risk of hypertension and dyslip-demia,12 but increased risk of diabetes and neu-otoxicity.13

Most reports of the use of tacrolimus in pa-ients with nephrotic syndrome are retrospectiver uncontrolled and include patients with hetero-eneous severity and renal histological character-stics.14-16 Tacrolimus was found to be effectiven inducing remission in 35% to 93% of patientsith SRNS who were resistant to CsA.15,16 How-

ver, there is a lack of randomized controlledrials comparing the efficacy of these agents inatients with nephrotic syndrome. Based on theypothesis that tacrolimus is more effective thansA in inducing remission in patients with SRNS,e compared the efficacy and safety of 12 monthsf treatment with these agents.

METHODSThis study was conducted from August 2005 to July 2007

t the All India Institute of Medical Sciences (New Delhi), aeferral center in north India. The study, which included 12onths each for enrollment and follow-up, was approved by

he Ethics Committee; permission was also obtained fromhe Drug Controller General of India.

tudyPopulation

Consecutive patients between 1 and 18 years of age withdiopathic SRNS and renal histological characteristics sug-estive of minimal change disease (MCD), mesangioprolif-rative glomerulonephritis, or focal segmental glomeruloscle-osis (FSGS) were eligible. Patients who received treatmentith CsA or tacrolimus at any time or immunosuppressive

gents other than prednisolone in the preceding 12 weeksere excluded. Patients with nephrotic syndrome secondary

o membranoproliferative glomerulonephritis or membra-ous nephropathy, serum creatinine level greater than 1.5g/dL, estimated glomerular filtration rate17 less than 60L/min/1.73 m2, time between onset of steroid resistance

nd inclusion longer than 24 months, and history of diabetesellitus or liver disease were excluded. Written consent was

btained from either of the parents before enrollment.Nephrotic syndrome was defined as the presence of ne-

hrotic-range proteinuria (3� or greater) by means of dip-tick, spot urine protein-creatinine (Up/Uc) ratio greaterhan 2 g/g, hypoalbuminemia with albumin less than 2.5/dL, and edema. SRNS was defined as the absence ofemission despite treatment with prednisolone at a dose of 2g/kg/d for 4 weeks. Initial resistance was the presence of

teroid resistance at the onset. Patients showing remission at

nset, but SRNS in a subsequent relapse, were classified as h

ate resistance. Kidney biopsy specimens were examined bysing light and immunofluorescence microscopy and catego-ized as MCD, mesangioproliferative glomerulonephritis,nd FSGS by using standard criteria.18

Molecular analysis was performed on all 8 exons of NPHS2the gene encoding podocin; GenBank accession no.AJ279254)nd all 10 exons of WT1 (the gene encoding Wilms tumor 1rotein; GenBank accession no. NM_000378). Exons weremplified by using polymerase chain reaction, as describedreviously,19,20 and products were screened for sequence alter-tion by using conformation-sensitive gel electrophoresis.21,22

olecular analysis also was simultaneously performed in allarticipants by using direct sequencing of all 8 exons of thePHS2 gene and exons 8 and 9 of the WT1 gene at theepartment of Pediatrics and Human Genetics, University ofichigan (courtesy of Professor Friedhelm Hildebrandt).

rotocol

Eligible patients were randomly assigned to receive treat-ent with either tacrolimus or CsA. Randomization lists

sing permuted blocks of variable size were computer gener-ted off-site by a colleague not involved in the study.llocates of individual patients were sealed in seriallyumbered opaque envelopes that were opened at randomiza-ion. Therapy with tacrolimus was initiated at a dose of 0.1o 0.2 mg/kg/d (Pangraf; Panacea, Mumbai, India; 0.5- and-mg capsules) or CsA at 5 to 6 mg/kg/d (Panimun Bioral;anacea; 25- and 50-mg capsules, 100-mg/mL suspension)

n 2 divided doses before meals. The medication was givenor 12 months unless the patient exited the study because ofreatment failure. Patients in both groups received oral pred-isolone (on alternate days) at a dose of 1 mg/kg for 6 months,ollowed by 0.5 mg/kg for the next 6 months, and enalapril (0.2o 0.3 mg/kg/d). If required for blood pressure control,23 theose of enalapril was increased (0.4 to 0.5 mg/kg) or additionalreatment was instituted (amlodipine, 0.1 to 0.3 mg/kg/d).articipants with serum cholesterol levels greater than 200g/dL were treated with atorvastatin (5 to 10 mg/d). All

atients received daily supplements of calcium carbonate (250o 500 mg) and vitamin D. Trough (12-hour) levels of tacroli-us and CsA were measured by using microparticle enzyme

mmunoassay and radioimmunoassay, respectively, at 2 weeksnd 6 months during relapses or if they showed persistentephrotoxicity. The desired level for tacrolimus was 5 to 8g/mL, and for CsA, 100 to 150 ng/mL; lower levels wereccepted if patients were in remission.

ollow-up

Follow-up visits were scheduled fortnightly for 1 monthnd then every month. Physical examination and screeningor side effects were performed at each visit. Laboratoryvaluation included urinalysis (spot Up/Uc ratio) and estima-ion of blood levels of glucose, creatinine, electrolytes,lbumin, transaminases, alkaline phosphatase, and lipids.reatment adherence was assessed by means of pill count of

he returned packs; a 1-month supply of the medication wasrovided. At 12 months, a photograph of the patient’s teethas graded by a blinded observer as: (1) none, (2) mildingival overgrowth, (3) moderate overgrowth (involving

alf the crown), and (4) severe overgrowth (more than half

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he crown).24 A picture of the back was assessed for hypertri-hosis. Reversible nephrotoxicity was defined as an increasen serum creatinine level greater than 50% more than base-ine that improved after reducing the dose of CsA or tacroli-us by 50% for 15 days. Persistent nephrotoxicity was

efined as a similar increase in serum creatinine level thatersisted despite dose reduction for 15 days.25 The dose waslso decreased if transaminase levels were greater than 150U/L, bilirubin level was greater than 2.5 mg/dL, trough CsAevel was greater than 200 ng/mL, and tacrolimus level wasreater than 10 ng/mL.The occurrence of complete or partial remission after 6onths of treatment was considered a favorable response.omplete remission was defined as the absence of protein-ria (Up/Uc ratio � 0.2 g/g) and normal serum albuminevel of 2.5 g/dL or greater; partial remission, as non-ephrotic proteinuria (Up/Uc ratio of 0.2 to 2.0 g/g) andormal serum albumin level; and nonresponse was persis-ent nephrotic-range proteinuria (Up/Uc ratio �2 g/g) orypoalbuminemia with albumin less than 2.5 g/dL. Treat-ent failure was defined in patients showing nonresponse

espite 6 months of treatment, persistent nephrotoxicity, oreath. Patients who achieved remission, but experiencedelapse (urine protein of 3� for � 3 consecutive days,p/Uc ratio � 2) were treated with prednisolone at 2g/kg/d until remission (maximum, 3 weeks), followed by

.5 mg/kg on alternate days for 4 weeks, with tapering.

nalysis

The primary end point was comparison of the proportionf patients achieving complete or partial remission at the endf 6 months of therapy. Secondary outcome variables in-luded time to achieve remission, proportion of participantsn remission at 12 months, frequency of relapses, and sideffects. Glomerular filtration rate was estimated at 12 monthsy using the Schwartz formula17 and plasma clearance ofechnetium-labeled diethylene triamine pentaacetic acid.

Analyses were performed on an intention-to-treat basis.ata were analyzed using Stata, version 9.1 (StataCorp,ollege Station, TX). Continuous data are presented asean, 95% confidence interval (CI), and range unless other-ise stated. Categorical variables were analyzed using �2 orischer exact test, and relative risk (RR) with 95% CI wasalculated. Continuous variables were compared using t-est. Kaplan-Meier analysis was used to determine the prob-bility of nonresponse to therapy in relation to time. A Coxroportional hazard model was performed to determine theffect of treatment on remission and was expressed as hazardatio (HR). The assumption of proportional hazards washecked by using log-log survival curves, observed versusxpected survival curves, and Schoenfeld residuals.

RESULTS

Of 58 patients assessed, 17 were excluded (14id not meet eligibility criteria, and 3 did notonsent; Fig 1). Of participants randomly as-igned, 21 were assigned to receive treatmentith tacrolimus, and 20, with CsA. There was no

oss to follow-up, and all patients were included 0

n the analysis. Protocol deviation was present inpatients (2 in the tacrolimus and 1 in the CsA

roup) who continued to receive medication de-pite nephrotic-range proteinuria at 6 monthsecause serum albumin level was 2.5 g/dL orreater.

aselineCharacteristics

There were no differences in the 2 groups inaseline clinical, laboratory, and histological fea-ures (Table 1). Seventeen patients (10 in theacrolimus and 7 in the CsA group) had previ-usly received treatment with oral or IV cyclo-hosphamide (n � 14), IV methylprednisoloner dexamethasone (n � 8), and mycophenolateofetil (n � 1) without success. At the time of

nclusion, all participants were edematous andad nephrotic-range proteinuria and hypoalbu-inemia.Therapy with tacrolimus was started at a mean

aily dose of 0.12 mg/kg (95% CI, 0.11 to 0.13;ange, 0.1 to 0.16 mg/kg), and CsA, at 5.02g/kg (95% CI, 4.91 to 5.13; range, 4.7 to 5.5g/kg). The respective doses at the end of 12onths of therapy were 0.10 mg/kg/d (95% CI,

.09 to 0.11; range, 0.05 to 0.15 mg/kg/d) and

.07 mg/kg/d (95% CI, 3.60 to 4.54; range, 2.5 to

.5 mg/kg/d). Mean trough levels for tacrolimusnd CsA 2 weeks after starting the medicationere 4.6 ng/mL (95% CI, 3.9 to 5.3; range, 2.4 to.1 ng/mL) and 124.8 ng/mL (95% CI, 105.7 to43.8; range, 66 to 231 ng/mL), respectively.

esponseAfter 6 and12Months of Therapy

At the end of 6 months, remission occurred in8 patients (85.7%) on tacrolimus therapy (9omplete and 9 partial) compared with 16 pa-ients (80%) on CsA therapy (10 complete and 6artial). The likelihood of remission was similarn patients receiving tacrolimus and CsA at 6RR, 1.07; 95% CI, 0.81 to 1.41) and 12 monthsRR, 1.14; 95% CI, 0.84 to 1.55; Table 2). Figure 2hows the probability of nonresponse in relationo time. At 52 weeks, proportions of patientshowing nonresponse in those treated with tacroli-us and CsA were 9.5% (95% CI, 1.6 to 26.1)

nd 15% (95% CI, 3.7 to 33.4), respectively. Theate of complete or partial remission was 1.23imes greater for those treated with tacrolimusompared with CsA (hazard ratio, 1.23; 95% CI,

.64 to 2.37; P � 0.5). Median times to complete

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Tacrolimus Versus CsA in Nephrotic Syndrome 763

r partial remission were similar at 8 and 12 weeksn the tacrolimus and CsA groups, respectively. Atweeks, trough levels of tacrolimus were similar inatients in remission compared with those withonresponse (P � 0.6). Similarly, blood levels ofsA in patients with remission were similar to

hose with nonresponse (P � 0.9).Of 23 patients with initial resistance, 1 patient

ad heterozygous substitution of guanine to ad-nine (c.686G¡A; nucleotide numbering based onhe translation initiation codon at position �1)eading to an amino acid change of arginine tolutamine at amino acid 229 (p.Arg229Gln; proteinlteration inferred based on DNA sequence) and 1ad a compound heterozygous substitution compris-ng c.686G¡A and c.965G¡C (which leads to anmino acid change of arginine to proline at residue22 [p.Arg322Pro]) of the NPHS2 gene. The formerchieved partial remission and the latter had complete

Figure 1. Flow of partici-ants through each stage.Protocol deviates continued toeceive the intervention medi-ation despite having nephrotic-ange proteinuria at 6 monthsecause an increase in serumlbumin level was observed. Ab-reviations: GFR, glomerular fil-ration rate; MPGN, membrano-roliferative glomerulonephritis.

emission on tacrolimus therapy. A heterozygous si- t

ent sequence variant, c.954T¡C (p.Ala318Ala), wasound in 1 patient each in the tacrolimus and CsAroups. Both had initial steroid resistance, buthowed complete remission with therapy. Noatient with late steroid resistance showed se-uence variations involving the WT1 and NPHS2enes.

elapses

Two patients (both with MCD) of the 18 whochieved remission after treatment with tacroli-us experienced 3 relapses. Of 16 patients in

emission on CsA therapy, 8 (5 MCD, 2 FSGS,nd 1 mesangioproliferative glomerulonephritis)xperienced 13 relapses. A greater proportion ofatients receiving CsA experienced relapse com-ared with tacrolimus (RR, 4.5; 95% CI, 1.1 to8.2; P � 0.01). All relapses except 1 wereteroid sensitive. Mean durations of therapy at

he time of relapse were 38 weeks (range, 32 to

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4 weeks) in the tacrolimus group and 26 weeksrange, 12 to 40 weeks) in the CsA group. Meanrough levels of medications at relapse were 5.2g/mL (range, 2.2 to 8.2 ng/mL) and 107.4g/mL (range, 67.7 to 166 ng/mL) for tacrolimusnd CsA, respectively. These levels were similaro those in patients with no relapses.

therOutcomeVariables

At 12 months (Table 3), patients receivingacrolimus had nonsignificantly greater bloodevels of albumin. Although participants in both

Table 1. Baseline Clinic

Variables Tacr

ge at enrollment (mo) 75 (53.0uration of disease (mo) 15.9 (8.5uration of steroid resistance (mo) 5.3 (2.9oys 1

nitial:late resistanceeight SDS 0.04 (�0.4eight SDS 0.05 (�0.41ypertensionushingoid featureslbumin (g/dL) 1.8 (1.6holesterol (mg/dL) 411.3 (345.5reatinine (mg/dL) 0.56 (0.5lucose (mg/dL) 92.1 (89.5FR (mL/min/1.73 m2) 104.6 (94.5rine protein-creatinine ratio (g/g) 9.8 (3.9inimal change diseaseesangioproliferative glomerulonephritisocal segmental glomerulosclerosis

Note: Continuous data shown as mean (95% confidencenits: blood creatinine in mg/dL to �mol/L, �88.4; albuminlucose in mg/dL to mmol/L, �0.05551; GFR in mL/min/1.7Abbreviations: GFR, glomerular filtration rate; SDS, stan

Table 2. Response Afte

Tacrolimus(n � 21)

esponse at 6 moComplete remission 9 (42.8%)Partial remission 9 (42.8%)Complete or partial remission 18 (85.7%)Treatment failure 3 (14.3%)esponse at 12 moComplete remission 10 (47.6%)Partial remission 8 (38.1%)Complete or partial remission 18 (85.7%)Treatment failure 3 (14.3%)

Note: This table displays the relative risk of remission as

isk was calculated for each type of remission versus patients not

roups showed significant decreases in bloodevels of cholesterol, the decrease was greater inhose receiving tacrolimus. After 12 months ofherapy, estimated glomerular filtration rate de-reased significantly in both groups; differencesetween groups were not significant (P � 0.1).ubgroup analysis showed that therapy with CsAas more likely to achieve complete remission

n patients with late resistance (8 of 9 patients)ompared with initial resistance (3 of 11 patients;� 0.009). A similar pattern was not found in

atients receiving tacrolimus. Post hoc analy-

Laboratory Parameters

n � 21) Cyclosporine (n � 20)

) [12 to 186] 62.6 (43.1 to 82.1) [20 to 144]3) [3 to 65] 15.1 (9.2 to 21.0) [4 to 50]) [1 to 20] 6.1 (3.9 to 8.2) [1 to 16]%) 11 (55%)

11:96) [�1.1 to 4] �0.05 (�0.45 to 0.36) [�1.0 to 1.9]) [�1.4 to 2.5] �0.05 (�0.52 to 0.43) [�1.4 to 1.8]%) 6 (30%)%) 7 (35%)[0.9 to 2.4] 1.6 (1.4 to 1.8) [0.9 to 2.4].1) [240 to 845] 437.8 (361.4 to 513.8) [215 to 848][0.4 to 0.9] 0.51 (0.4 to 0.6) [0.4 to 0.8]) [80 to 100] 91.4 (88.7 to 94.0) [83 to 108]

7) [66 to 158.1] 115.5 (101.6 to 129.4) [62.8 to 162.3]) [2.6 to 57] 8.0 (5.4 to 10.6) [2.1 to 20]%) 9 (45%)%) 3 (15%)%) 8 (40%)

l) [range]. All P values were � 0.1. Conversion factors forL to g/L, �10; cholesterol in mg/dL to mmol/L, �0.0259;mL/s/1.73 m2, �0.01667.viation score.

12 Months of Therapy

Cyclosporine(n � 20)

Relative Risk (95%confidence interval) P

10 (50%) 0.85 (0.44-1.65) 0.66 (30%) 1.42 (0.62-3.2) 0.4

16 (80%) 1.07 (0.81-1.41) 0.64 (20%)

11 (55%) 0.86 (0.47-1.57) 0.64 (20%) 1.90 (0.67-5.34) 0.2

15 (75%) 1.14 (0.84-1.55) 0.45 (25%)

d with the use of tacrolimus versus cyclosporine; relative

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Tacrolimus Versus CsA in Nephrotic Syndrome 765

is of data showed that participants whochieved remission (n � 35) had lower meanp/Uc ratios at baseline compared with thoseith nonresponse (n � 6; P � 0.03). Theccurrence of remission was not related tother clinical or histological features, medica-ion used, or its levels.

Treatment failure in patients on tacrolimusherapy (3 patients) included 1 each with persis-

Figure 2. Kaplan-Meier survival curve shows the pryclosporine (CsA) or tacrolimus (Tac). The number of patonfidence interval.

Table 3. Laboratory Paramet

Tacrolimus(n � 19*)

erum albumin (g/dL) 4.4 (4.01 to 4.78) [2.4 to 5.8]erum creatinine (mg/dL) 0.68 (0.65 to 0.74) [0.5 to 0.9]erum cholesterol (mg/dL) 142.7 (129.5 to 155.9) [108 to 208lucose (mg/dL) 95 (92.5 to 97.4) [88 to 107]rine protein-creatinineratio (g/g) 0.5 (0.21 to 0.79) [0.01 to 2.2]

chwartz GFR (mL/min/1.73 m2) 90.2 (82.9 to 97.5) [66 to 132]

TPA GFR (mL/min/1.73 m2) 96.5 (86.1 to 106.9) [52 to 124]ecrease in SchwartzGFR† (%) �12 (�21.4 to �2.7) [�46.8 to 27.

Note: Values expressed as mean (95% confidence intervo �mol/L, �88.4; albumin in g/dL to g/L, �10; cholester0.05551; GFR in mL/min/1.73 m2 to mL/s/1.73 m2, �0.01Abbreviations: DTPA, diethylene triamine pentaacetic ac*Participants not included in analysis: tacrolimus, 2 (pers

ephrotoxicity, 2; no response, 2).

†Decrease in GFR over 12 months of therapy.

ent nephrotoxicity (at 8 weeks of therapy) andonresponse (trial deviate at 6 months); 1 patientith complete remission at 8 weeks died becausef severe pneumonia and sepsis at 8 months.edication was discontinued in 5 patients receiv-

ng CsA, including 2 each with persistent nephro-oxicity (at 12 weeks and 8 months of therapy)nd nonresponse (both at 6 months) and 1 withecondary resistance (at 7 months; Fig 1).

ty of nonresponse during 12 months of treatment witht risk is given at the bottom of the graph. Abbreviation: CI,

nd of 12 Months of Therapy

Cyclosporine(n � 16*)

Mean Difference (95%confidence interval) P

3.9 (3.42 to 4.38) [1.8 to 5.2] �0.5 (�1.1 to 0.1) 0.080.63 (0.49 to 0.70) [0.4 to 1] �0.05 (�0.1 to 0.04) 0.3

7.9 (162.7 to 213.1) [117 to 278] 45.1 (19.1 to 71.2) 0.00194.8 (91.8 to 97.9) [86 to 106] 1.8 (�3.8 to 3.6) 0.9

.6 (�0.20 to 1.40) [0.01 to 6.2] 0.1 (�0.7 to 0.9) 0.8

.3 (88.7 to 109.9) [57.8 to 130.6] 9.2 (�2.9 to 21.2) 0.194.7 (85.3 to 104.1) [72 to 120] �1.8 (�18.2 to 14.6) 0.8

1.3 (�24.3 to 1.7) [�40.4 to 33.9] 0.7 (�14.3 to 15.8) 0.9

ge]. Conversion factors for units: blood creatinine in mg/dLg/dL to mmol/L, �0.0259; glucose in mg/dL to mmol/L,

, glomerular filtration rate.ephrotoxicity, 1; death, 1); and cyclosporine, 4 (persistent

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ide Effects

Nephrotoxicity was seen in 8 and 12 patientsreated with tacrolimus and CsA, respectively.he toxicity was usually reversible (Table 4). Noatient showed new-onset hypertension, al-hough the dose of enalapril was increased toreat hypertension in 2 participants in each group.

oderate gingival hypertrophy and hypertricho-is were common in patients on CsA therapy, andiarrhea was seen in patients receiving tacroli-us. There were transient increases in transami-

ase levels not requiring reduction of dose in 5nd 6 patients in the tacrolimus and CsA groups,espectively. Blood glucose and potassium levelsere within normal limits.

DISCUSSION

This is the first randomized controlled trialomparing the efficacy and safety of tacroli-us with CsA in patients with idiopathic SRNS.significant proportion of participants had

reviously failed to respond to treatment withV/oral cyclophosphamide or IV corticoste-oids. At the end of 6 months, complete andartial remissions were seen in 85.7% and 80%atients treated with tacrolimus and CsA, re-pectively. At the end of 12 months of therapy,he probability of not achieving complete orartial remission was 9.5% in the tacrolimusroup and 15.0% in the CsA group. Our find-ngs indicate that therapy with tacrolimus or

Table 4. Relative Risk of Side Effects Associat

Cyclosporine(n � 20)

enalPersistent nephrotoxicity 2 (10%)Reversible nephrotoxicity 10 (50%)Worsening of hypertension 2 (10%)eurologicalHeadache 0Paresthesia 0osmeticHypertrichosis 19 (95%)Gingival hyperplasia 12 (60%)Acne, skin infection* 5 (25%)iarrhea 1 (5%)epsis, pneumonia 1 (5%)

*Acne, skin infections: tacrolimus (acne, 1; impetigo, 1);cabies, and seborrhea).

sA is comparable in inducing complete or o

artial remission in most patients with SRNS.lthough not all experienced complete remis-

ions, we believe that the occurrence of evenartial response is useful in the long term.imilar response rates, ranging from 60% to0%, have been reported after therapy withsA.8,9,26 A relatively greater response in theresent study might be caused by inclusion ofatients with both initial and late resistance,eterogeneous renal histological characteris-ics, and cotherapy with enalapril and pred-isolone. Similar findings from uncontrolledtudies suggest that tacrolimus is effective inchieving complete or partial remission in 85%o 95% of patients.16,27,28

In the present study, we did not target prefixedevels of the medication. Although we aimed forrough levels of tacrolimus and CsA between 5nd 8 ng/mL and 100 to 150 ng/mL, respectively,ower levels were accepted if the patients were inemission. The mean daily dose of tacrolimusanged between 0.10 and 0.12 mg/kg, and therough level at 2 weeks was 4.6 ng/mL. Othernvestigators have used greater (0.15 to 0.37g/kg) doses of tacrolimus and attained greater

evels (8.3 to 10.3 ng/mL).15,16,27,28 Similarly,osages and blood levels of CsA were lowerompared with other reports.11 It is noteworthyhat despite lower dosage and lower trough lev-ls, 85.7% of patients on tacrolimus therapy and5% on CsA therapy were in remission at the end

h the Use of Cyclosporine Versus Tacrolimus

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(4.7%) 0.3(4.7%) 0.3

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Tacrolimus Versus CsA in Nephrotic Syndrome 767

ower doses of medications may have implica-ions in minimizing their side effects.

Previous reports suggest that 10% to 76% ofatients experience relapse after cessation ofreatment with calcineurin inhibitors.10,15,27 How-ver, there is limited information about occur-ence of relapses during therapy. In a retrospec-ive analysis of children with SRNS, 20% ofarticipants receiving tacrolimus experienced re-apse compared with 11% in the present study.16

esults from the present study show that theelapse rate during treatment was significantlyreater with CsA compared with tacrolimus. Therigger for most relapses was an upper respira-ory tract infection, and the relapses responded toreatment with daily corticosteroids. In the presenttudy, patients in both groups showed decrease inlood cholesterol levels, although the reductionas significantly greater with tacrolimus com-ared with CsA. Because dyslipidemia is a riskactor for atherosclerosis, cardiovascular mortal-ty, and chronic kidney disease, its control afterhe use of either of the calcineurin inhibitors isromising. The relative long-term benefits ofacrolimus compared with CsA in this respecteed to be examined further.12

Sequence alteration involving the NPHS2 geneave been reported in 20% to 30% of patientsith idiopathic SRNS.29 In previous studies,one of the patients with a homozygous or com-ound heterozygous mutation in the NPHS2chieved complete remission on CsA therapy.29,30

uf et al29 reported partial response in 17% ofatients with SRNS treated with CsA. In theresent study, no participant had a homozygousPSH2 mutation, and 1 had a compound het-rozygous mutation. The latter achieved com-lete remission after treatment with tacrolimus.he significance of heterozygous sequence vari-nts for the disease phenotype remains unclear.29

he R229Q (p.Arg229Gln) mutation alone isnsufficient to cause FSGS, but appears to en-ance susceptibility to renal injury in a homozy-ous or compound heterozygote state.22 Addi-ional studies are required to evaluate the role ofalcineurin inhibitors in patient with SRNS andomozygous or compound heterozygous se-uence alterations in NPHS2. Similar to previousbservations, we found that no patient with lateteroid resistance had sequence alterations involv-

ng the NPHS2 or WT1 genes.31 m

Nephrotoxicity, an important side effect ofreatment with calcineurin inhibitors, was moni-ored closely during this study. A proportion ofatients showed evidence of acute nephrotoxic-ty that reversed after reduction in the dose ofalcineurin inhibitors. All these patients re-ained in remission, and no further episodes of

ephrotoxicity were observed. The risk of persis-ent nephrotoxicity and decrease in glomerularltration rate at 12 months was similar in patients

reated with tacrolimus and CsA, similar to thatoted by other investigators.32

Cosmetic side effects, including gingival hy-ertrophy, hypertrichosis, and acne, were foundn a significant proportion of children treatedith CsA (Table 4). Mahmoud et al10 reportedum hyperplasia (20%) and hypertrichosis (49%)s the most frequent side effects observed withsA therapy. The findings of increased risks ofiarrhea and hypercholesterolemia after treat-ent with tacrolimus and CsA confirm those by

ther investigators, respectively.12,13 Transplantecipients receiving tacrolimus, especially thoseith high trough levels, are considered at risk ofew-onset diabetes.13 In an observational study,% of children with SRNS on tacrolimus therapyhowed hyperglycemia.28 The use of a lowerose and lower drug levels might explain thebsence of glucose intolerance or new-onset dia-etes in our patients.The chief limitation of this study was that a

mall number of patients with SRNS were re-ruited, reducing its power and strength of con-lusions. Although the primary outcome wasimilar in patients receiving treatment with ta-rolimus or CsA, statistically significant differ-nces with wide CIs were found in some second-ry outcomes. The study population wasomposed of clinically and histologically hetero-eneous patients from a single center with shortollow-up. Patients with late resistance are likelyo respond better to therapy and favorably impactn the results of treatment. Monitoring drugevels was not rigorous. Finally, although achieve-

ent of complete or partial remission is assumedo reduce the risk of progressive kidney disease,he long-term benefits and safety of these agentsas not examined. Despite these limitations, this

s the first prospective randomized controlledrial comparing 2 promising medications for treat-

ent of patients with SRNS. Genetic studies

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ere performed in all patients at inclusion, al-hough the results did not result in their exclusionrom the study. There was close monitoring foride effects, minimal trial deviates, and no pa-ient was lost to follow-up.

Findings from this study suggest that therapyith tacrolimus or CsA in combination with

ow-dose steroids shows similar efficacy in induc-ng remission in a considerable proportion ofatients with SRNS. Although patients receivingacrolimus showed lower relapse rates, de-reased blood levels of cholesterol, and lack ofosmetic side effects, these were secondary endoints. Although therapy with tacrolimus mighte considered a reasonable alternative to CsA foratients with idiopathic SRNS, adequately pow-red studies with longer follow-up are necessaryo confirm the relative benefits of prolongedherapy with these agents. It also is important toxamine whether the remission induced withacrolimus or CsA is sustained at lower doses oreplacement with agents that are not nephro-oxic.

ACKNOWLEDGEMENTSThis study was presented at the Congress of the Interna-

ional Pediatric Nephrology Association, Budapest, Hun-ary, in August 2007. We thank Professor F. Hildebrandt,epartment of Pediatrics and Human Genetics, Universityf Michigan, for the mutational analysis.Support: Study medications (CsA and tacrolimus) were

rovided by Panacea Biotec, India.Financial Disclosure: None.

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Tacrolimus Versus CsA in Nephrotic Syndrome 769

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